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©Center for Promoting Education and Research (CPER) USA,www.cpernet.org

International Journal of Humanities and Applied Social Science (IJHASS)

E-ISSN: 2471-7576 September 2020, Vol: 5, Issue: 9 E-mail: [email protected] http://ijhassnet.com/ DOI: 10.33642/ijhass.v5n9p2

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An insight into Case Management and Challenges in Veteran Suicide Prevention

Tamara Green

The Australian Defence Force Academy

UNSW Canberra

Email: [email protected]

Australia

ABSTRACT

Much of the literature, policies, programs, and investment has been made on mental health, case management, and suicide prevention of veterans. The Australian “veteran community is facing a suicide epidemic for the reasons that are extremely complex and beyond the scope of those currently dealing with them.” (Menz, D: 2019). Only limited work has considered the digital transformation of loosely and manual-based historical records and no enablement of Artificial Intelligence (A.I) and machine learning to suicide risk prediction and control for serving military members and veterans to date. This paper presents issues and challenges in suicide prevention and management of veterans, from the standing of policymakers to stakeholders, campaigners of veteran suicide prevention, science and big data, and an opportunity for the digital transformation of case management.

Keywords: Case Management, digital transformation, Veterans, Suicide prevention, suicide case-based

reasoning.

1.0 Introduction

The Australian Defence Force (ADF) serving members perform a variety of roles in their duties with the main

objective to defend Australia in the event of an armed attack. The contribution made by both military members and

veterans through their role to provide national defence, security, peace and freedom is highly valued. However, there

is a serious social issue within the veteran community, the Government has acknowledged the prevalence of veteran

suicide, veteran focused social media groups, several Labor politicians, veteran advocates & support groups and

campaigners raise the issue - our veterans are suiciding. “The suicide rate for young veterans is double the average.

One in five transitioning ADF members considers it. One in ten plans it. One a week goes through with it” reports

Senator Jacqui Lambie. Dave Menz, president of the Australian Peacekeeper and Peacemakers Veteran Association

Vic Branch discussed the incidence of suicide within the veteran community and the efforts made to date by

Government and the ex-service organizations have not yet stymied the problems and the causal links to the extreme

high numbers still remains unknown (2019). Research and reviews have been carried out throughout Australia, within

Federal and State Government and outside agencies to better understand suicide by veterans and ex-personnel.

Recommendations have been provided by the 2016 Senate Standing committee inquiry into veteran suicide including

piloting interventions at an individual and community level, including the address of case management to improve

suicide risk. This paper provides issues and key challenges faced by the veteran community, with suggestions of a way

forward.

Research Methodology

The proposed research is underpinned by the combination of sustainable science (Kates, 2016) and action-based

research (Dick, Stringer & Huxman, 2009). According to Kates (2016), sustainable science is very important for health

science studies, and it is use-case driven and focus on integration and translation of knowledge. It exacts the needs and

solutions to any given problem in association with place and time, and particularly focuses on finding solutions to

targeted world problems. It is aimed to provide integrative understanding among multi-disciplinary stakeholders and

to transform knowledge into actionable results. Dick, Stringer & Huxman (2009) discuss that action based research

involves theory building and testing, informed by knowing, understanding and sense making. In action research, cycles

of observation and recommendation guides the research development and utilizes participative practices that are

primarily qualitative in nature, drawing on social science, science and multidisciplinary based case studies, data

collection and analysis of heterogeneous data sources.

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2.0 Facts and Figures-An Insight into Case Management

The Australian CEO of Mental Health and Suicide Prevention Australia stated that, “suicide is one of the biggest

challenges of our time” (Maher, 2020). Prime Minister Scott Morrison’s press release said that, “Too many veterans

take their own lives. One veteran taking their own life is too many. 42 veterans took their life in the in the last set of

figures, annually that we have received” (Morrison, 2020). Soldier On is a community organisation funded by the

Australian Government to support the needs of veterans. The organisation wrote to the Senate Standing Committee and

voiced that, “We collectively need to do more to ensure veterans stop taking their lives. While Soldier On does believe

significant improvements can be made to the compensation and entitlement regulatory frameworks, systems and

processes, we do not believe that this will solve the issue. The process of transition from the ADF back into civilian

life needs to support the individual to leverage and evolve these mindsets and cultures to embrace the next phase of

their personal journey in building successful futures for themselves and their families (2016:12). The Attorney-General

of National Commissioner for Defence and Veteran Suicide Prevention was established in early 2020 as a response to

extreme pressure to reduce suicides in the Defence establishment. The government stated that, “the death by suicide of

any Australian Defence Force (ADF) member or veteran is tragic for the family, and felt by the entire community.

Preventing these suicides is a key priority for government”. On 27 August 2020, the Attorney-General introduced two

bills to the Parliament and commenced a public consultation process for consideration of The Bills which provide that

the National Commissioner will work to identify and understand the factors and systemic issues that may contribute to

suicide risk among serving and former ADF members, and make recommendations to government about actions and

strategies to prevent future deaths by suicide.

3.0 The Government Challenges of Case Management & Suicide Prevention

The Case Management Society of Australia & New Zealand & Affiliates (CMSA) define case management as

a collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an

individual’s holistic needs through communication and available resources to promote quality cost effective outcomes

(www.cmsa.org.au). According to Gursansky, Kennedy & Harvey the sustainability of case management has spanned

for approx. four decades and is practiced on a global scale. The individualization of service delivery has proceeded

relentlessly over the last 30 years, espoused and endorsed as variously meeting the goals of practitioners, consumers,

carers, service providers and policy-makers. Understandably, each of these stakeholders has viewed the approach in

terms of their own positioning…The co-ordination of services for the individual has meant support for the case

management from consumers as they are positioned to be greater involved in the planning and ongoing management

of their situations (2003).

The challenges for case management in veteran health and wellbeing are multifaceted with ineffective

processes, poor training in the veteran wellbeing and health matters and often due to paper-based systems. In October

2017, The Australian Government responded to the Foreign Affairs, Defence and Trade Committee report, The

Constant Battle: Suicide by Veterans and agreed to twenty-two recommendations. The recommendations for case

management methodology are significant to the current issue of suicide in the veteran community. The Australian

Government agreed to improve identification and management of veterans in at risk groups, by committing $4.0 million

over the next 2 years to pilot a personalized and veteran-centric case management service for at risk veterans who

require additional support immediately following their discharge from the military. This pilot program is aimed to

provide at risk veterans with a case manager, who will identify and facilitate access to support services. In addition to

the agreed Australia Government responses to the report, at Recommendation 15, it was agreed that serving ADF

members who are at risk should be offered more intensive transitional support service, DVA to support members

following their discharge and into their civilian live. The aim of the two years pilot program for case management

services for at risk veterans, is an initiative to increase early detection and intervention of mental and physical health

concerns immediately following discharge. The Australian Government acknowledges that during the transitional

period following discharge, intervention is necessary as this can be a, “risk period for the emergence of mental health

conditions and increased risk of suicide” (Australian Government Response to the National Mental Health Commission,

2017). Arthur Ventham, Chairman and Senior Advocate for the Northern Suburbs Veterans Support Centre that aside

from mental illnesses, there are several risk factors that may contribute to suicide, attempted suicide and actual suicide.

According to the most recent report published by the VA in 2016 (which analyzed 55 million veterans’ records from

1979 – 2014), the current analysis indicates that an average of 20 veterans a day die of suicide. The figures often quoted


http://www.cmsa.org.au/

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by Ex-Service Organizations (ESO’s) come from the contact with family and friends of those that have taken their own

lives. Ventham recommends that the Federal Government agency, “The Department of Veteran Affairs, adopt a case

management approach to claims whereby in each State a panel of Senior Delegates take control of a team of delegates

and controls the workload” (2016). Such coordination of case managers could alleviate communication breakdown

when workers are on leave or unavailable or do not return phone calls to the veteran with a claim in progress. The

Partners of Veterans Association of Australia stated that there is a need for a, “Case manager for at risk clients: its is

noted that undertakes a Needs Assessment of the veteran to assist delegates to determine the range of services and

benefits that may be required. The appointment of additional Case Coordinators from early this year is markedly

improving the Department’s [DVA] support of veterans at risk of self-harming and who have complex cases that

necessitate multi-agency coordination” (2016). The Returned Services Leagues noted that the suicide data is convoluted

with deaths that are not definitely suicides, “too many individuals are suffering from poorly managed circumstances at

the present time without the necessary care and supervision that’s required from a number of appointed agencies”

(Doolan:2011). A veteran support agency, Soldier On, stressed the importance of accurate and transparent data

regarding veteran suicide and noted that without accurate data, the support providers couldn’t address the issues. The

Australian Government report, Guarding Against Uncertainty: Australian Attitudes to Defence identified that concerns

were repeatedly raised about the effect of operational deployments on the psychological and physical wellbeing of

service personnel and their families, for the community consultation. The report states that, “several people, particularly

from health and social work backgrounds, emphasized the need for proper resourcing of the treatment and reintegration

of combat veterans, including to minimize the impact on relationships and society” (2015:13). There is a strong

community view worth noting that considers Government should put a priority on assisting veterans.

4.0 Social Challenges in Case Management & Suicide Prevention

In 2016, the Senate Foreign Affairs, Defence and Trade References Committee led the inquiry into suicide by

veteran’s ad ex-service personnel. A total of twenty-four recommendations were made in the Senate Committee report

based on the inquiry, The Constant Battle: Suicide by Veterans. The report was tabled in Parliament in August 2017

with the main objective to improve suicide prevention and to deliver the necessary support to ADF members, ex-serving

members and veterans with mentally-ill health and psychosocial problems. The progress implementation as at 31

January 2020, identified both substantially complete and completed actions in response to recommendations in the

Senate Committee report. The Australian Government Institute of Health and Welfare report identified that suicide is

an issue that affects all Australians. It is the leading cause of death for Australians aged 15-44, with around 8 people

dying by suicide a day. Current and former members of the ADF, and their families, are not immune to this. “Ex-

serving ADF personnel may face increased risk of suicide”. (AIHW: 2019).

Senator Jacqui Lambie responded to the Government’s announcement to the election of a Veteran

Commissioner with reservation. The Senator explained in Parliament that young veterans are killing themselves at

twice the national average and we lose a veteran a week. Adversely, the announcement was viewed as a press release

promising a Commissioner and a review into the past reviews. A total of 17 reviews have been held in the last 17 years.

“They all paint the same sad picture, and we’re still making the same mistakes. My inquiry in the last Parliament found

that veterans are seeking help from the Department of Veterans Affairs and having their claims delayed or denied

inappropriately because DVA staff are overworked and undertrained” (Lambie J. Sen, 2020).

The Department of Veterans’ Affairs (DVA) operates Australia’s compensation and rehabilitation scheme for

veterans with health conditions arising from their military service. Multiple recent inquiries and reviews of the DVA

support system have identified that the compensation claims assessment process may contribute to the psychological

distress and mental health conditions experienced by some veterans, including self-harm and suicide (Collie,

A.,2019:5). Australian Government, Australian Institute of Health and Welfare state that from 2001-2017 that there

were 419 suicides in serving, reserve and ex-serving ADF personnel who have served since 2001. Compared with

Australian men, and the age-adjusted rate of suicide over this period was 48% lower for men serving, and in the

Reserves, and 18% higher for ex-serving men. Over the same period, the age-adjusted rate of suicide among ex-serving

women was higher than that of Australian women (AIHW: 2019). An estimated 20% of transitioned ADF members

were reported to have experienced suicidality, including 2% who had attempted suicide and a further 7.9% who had

made a suicide plan. The rate of psychological distress in transitioned ADF (33.1%) was nearly twice that in serving

ADF members (18.7%) and nearly three times the rate in the Australian community (12.8%). A recent report by the


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Australian Institute of Health and Welfare (AIHW) supports these findings. The age-adjusted incidence of suicide in

ex-serving men (veterans) was 18% higher than the rate in all Australian men. Younger veterans appear to be at greater

risk. Veterans under the age of 30 had a rate of suicide 2.2 times higher than Australian men the same age for the period

2014-2016. The Department of Veteran Affairs state in the submission to the Senate Committee that although ADF

members display more symptoms and are likely to express ideation than people in the general community, they are

only equally likely to actually attempt suicide (2016:6).

An insight into the Submissions to the Australian Government Senate Standing Committee Inquiry into Suicide by

Veterans and Ex-Service Personnel:

A large cohort of veterans expressed their personal experiences, challenges and negative dealings with key

Government agencies in their submissions to the Australian Government inquiry into suicide by veterans and ex-

members. A high proportion of veteran submissions overwhelming held the view that case management and claim

processes were inadequate. One ex-serving military member advised the Senate Committee that, “In my experience

and that of other ex-servicemen and women I know almost all dealings with the DVA have been difficult and stressful.

It seems that when a claim is submitted the standard response is ‘NO’ thus leaving the member feeling dejected, let

down and disappointed over what they thought was a simple process to recognize the condition in relation to their

service” (Bunker:2016). Ineffective and lengthy delays in claims processes can affect the mental wellbeing of veterans.

Jessica Leonard (2016:1) stated that, “DVA claim acceptance/denial time is ridiculous, 3+ months to accept a claim.

Mental health sufferers like myself go through many anxiety attacks waiting and waiting also being sent to MLCOA

doctors when we have our own treating specialists”.

A veteran suggested the Australian Government to consider digital transformation from paper-based

administration and case management processes as the processes proved to be ineffective. “The streamlining of the DVA

claims process needs to be addressed immediately. When a member is diagnosed with a condition, that information

should immediately be sent to DVA and the claims processed electronically. This way most of the work would have

been done when that member does eventually discharge. We live in the electronic age now, and the amount of

paperwork that has to be completed is ridiculous. The Medical Officer can easily send any specialist diagnosis to DVA

for processing so that everything is on record when the member needs it most, at the end of hopefully a long career”

(Submission 79, Name Withheld: 2016).

Daniel Foley discussed his personal views on veteran suicide. “I believe depression and suicide rates are

increased when Veterans feel financially threatened or insecure, when they feel mismanaged or ill-treated by DVA and

when they are ignored by the very politicians that placed them in harm’s way”. Financial problems cause a loss in self-

worth, they cause families to break up and in doing so deny Veterans much needed family support. When DVA knocks

back a claim or pays some Veterans at lower rates than others and continually makes changes to legislation that erode

the "entitlements" of Veterans, you get an even greater lowering of self-worth, increases in depression, family break

up and suicide (2016). Veterans report the adverse feelings and poor case management experiences with Government

agencies. Overwhelmingly, the veterans report high levels of frustration due to the lack of information provided to

them about their claim from case workers. Other veterans identified challenges in their efforts to navigate through

administration processes of Government agencies.

Prof. Philip Morris is the executive Director of ANZMHA which is now known as Phoenix Australia Centre

for Posttraumatic Mental Health reports, “Many ADF personnel are not recognized at discharge as having a mental

illness, which often becomes overt later, and frequently service-related mental disorders take years to develop. In

addition, Dr Gail MacDonnell of the Australian Families of the Military Research Foundation asserts that the political

comparison of the rates of suicide amongst military personnel and the general population to be ‘grossly misleading’

because of the expected ‘healthy soldier effect’. With reference to the Department of Veterans Affairs sponsored study,

Suicide by veterans and ex-service personnel study, it was realized any results from comparing the health of National

Servicemen with their peers in the general community would be meaningless. As a group, those who fought in the

Vietnam war have had a higher suicide rate than a comparable group who did not fight the war. This finding will also

be true for recent wars because the same kind of military selection process has been used. It follows that each individual

who experiences the trauma of combat has an elevated risk of suicide (2016:3).

Carers Australia NSW report that given the high incidence of suicidality and mental health conditions among

veterans and ex-service personnel, the submission draws on research regarding mental health carers, including those


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exposed to suicide, in addition to evidence specifically relating to carers of veterans. Evidence suggests that carers of

veterans have an especially high incidence of mental health conditions across their life course as a result of their caring

role. Research indicates that mental health carers, especially those exposed to suicide, need simpler service pathways

and better information and support as they navigate service systems. Clinicians should also ensure that carers are

engaged in service planning and follow up after a suicide attempt. Alarmingly, a recent study found the wives of

Vietnam veterans also have elevated rates of thinking about, planning and attempting suicide. The children of Vietnam

veterans have had a 300% higher suicide rate than their equivalents in the general community, a statistic resulting from

veterans’ families becoming dysfunctional because of the veteran fathers’ war caused psychological illnesses. O’Toole

et. al (2015). The study also confirmed that there are robust associations between depression and suicidality in both

sexes, and that PTSD was associated with increasingly severity of suicidality in veterans and their partners (Carers

Australia NSW, 2016). Mr. Richard Stone an experienced veterans’ advocate and member of the Returned and Services

League of Australia stated in his submission to the inquiry that, “I believe the following factors contribute to veterans’

angst; a. The often lengthy processing times taken after a claim has been lodged including the like lengthy appeals

process which exacerbate these timings with a consequent detrimental impact on a veteran’s wellbeing. b. The evident

inconsistencies in decisions relating to like claims” (2016).

5.0 Data Governance Challenges in Case Management & Suicide Prevention

Our study shows there are 5 major key issues, namely:

(1) Inefficient governance of case management policies and processes, leading to poor service delivery and

maladministration of veteran health and well-being

(2) Lack of legislation and terms of reference about compensation leading to poor visibility and transparency in

veteran health management.

(3) The traditional methods including clinical and medical studies leading to low level of accuracy in prediction of

suicide risks is a very high in cost to the veteran community

(4) Paper-based case management systems among stakeholder leading to for the recording and execution of the

government policy, process, service delivery.

(5) Undermine the social studies compared to clinical studies for the root cause analysis, including handling and

the implementation of the polices, processes, human services, workflows, and quality of veteran service

delivery.

5.1 No validation of the case management policies and processes, leading to poor service delivery and

governance of veteran affairs.

In August 2017, the Senate Standing Committee on Foreign Affairs, Defence and Trade delivered its report

following an inquiry into suicide by veterans and ex-service personnel; The Constant Battle: Suicide by Veterans. The

report at Recommendation 13 initiated that the Australian National Audit Office commence the proposed performance

audit of the efficiency of veterans’ service delivery by DVA as soon as possible.

The Australian National Audit Office (ANAO) conducted an audit of the DVA business systems to obtain process

findings. The main objective of the audit was to assess whether DVA was efficiently delivering services to veterans

and their dependents. To form a conclusion against the audit objective, the Australian National Audit Office (ANAO)

adopted the following high-level audit criteria:

Do business systems and processes in DVA support the efficient delivery of services to veterans and their

dependent’s?

Has compensation, support and health services been delivered efficiently by DVA to veterans and their

dependent’s?

The audit identified weaknesses in DVA’s business systems and processes, which do not adequately support

the efficient delivery of services. In particular, DVA should improve the structure and consistency of workflow

management for R&C claims and review its highly segmented approach to processing claims under the various

elements of applicable legislation. The Constant Battle: Suicide by Veterans report identified that, ‘The need to

streamline the administrative practices of DVA was the overwhelming concern of most submissions to the inquiry’.

DVA should improve its oversight of the progress of individual claims through the processing lifecycle, and its

management of medical service provision. The monitoring and reporting of claims is not effective in alerting


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management to those which are at risk of taking excessive time to process (ANAO, 2019). In addition, without

collecting social service data among the stakeholders, it is difficult to justify the effectiveness of the policies and

processes, and the quality of the implementation of those policies and processes.

One of the important issues is that there is no validation of the effectiveness of the case management policies

and processes. The National Mental Health Commission Review (March 2017) identified that a case management

service was necessary for the support of veterans and their families who have complex medical needs, and to manage

issues of self-harm and suicide prevention. The DVA and Australian Government have taken an active approach

through the pilot of case management services, The Wellbeing and Support Program which commenced on 1 July 2018

to provide support to recently transitioned members, and veterans who may have fallen in crisis (DVA, 2020).

Emerging contemporary services and technological advancements in areas of mental health are available to

military and ex-serving community, to support the changing needs required for the veterans and their families. The

Open Arms Veterans & Families Counselling website has access to essential apps and online resources for 24 hours

support for veterans and their families. Positively, the apps and online resources are available to assist in maintaining

mental and physical health by helping veterans in a range of circumstances ranging from dealing with suicidal thoughts,

the management of symptoms incurred from trauma, building stress and resilience and the management of alcoholic

consumption (www.openarms.gov.au, 2020). The Open Arms Veterans & Families Counselling portal and Veterans

and Veterans Families Counselling Service (VVCS) websites serve as primary digital entry points for information on

mental health and how to access professional support. The VVCS website enables veterans and their families to self-

manage their mental health through veteran-specific and community-based digital interventions. In addition to these

resources, other mobile apps (including; PSTD Coach Australia, High Res, The Right Mix) e-learning programs, social

media pages (Facebook & Instagram) are available to address mental wellbeing and promote support services available

to veterans.

5.2 Lack of legislation and terms of reference about compensation processes leading to poor visibility and

transparency in veteran health management

There has been no legislation or Terms of Reference into veteran suicide. The Skynews.com.au reported that

the “Minister of Defence proceeded to review veteran suicide but they don’t investigate and cover up and criminality

where veterans are concerned” (Finney: 2020)

Dr. Jon Lane (2016) reported that he felt that the primary issues behind the increasing rates of suicide were due

to two primary factors: The inherent administrative difficulties in navigating and completing the DVA / Commonwealth

Super processes, and the loss of social connectedness and functionality that occurs after medical discharge from ADF.

According to the Australian Government, Productivity Commission. A Better way to Support Veterans report the

current veterans’ compensation and rehabilitation system does not perform well when assessed against the principles

that should underpin the future system. This is in part because of the way the system has been added to over time, but

also because of the way the system is set up and the incentives it creates for Defence, DVA and veterans. Veterans and

their families could be getting far better outcomes from the dollars the Australian community is spending to improve

their lives. The Australian Government, Productivity Commission report details the compensation and rehabilitation

process with emphasis on providing evidence-based advice about policies that will improve the lives of current and

future generations of veterans and their families, while also improving outcomes for the community as a whole. Despite

some recent improvements to the veterans’ compensation and rehabilitation system, it is not fit-for-purpose — it

requires fundamental reform. The system fails to focus on the lifetime wellbeing of veterans. It is overly complex

(legislatively and administratively), difficult to navigate, inequitable, and it is poorly administered (which places

unwarranted stress on claimants). Some supports are not wellness-focused, some are not well targeted, and others are

archaic, dating back to the 1920s. The institutional and policy split between Defence and DVA also embeds perverse

incentives, inefficient administration and poor accountability, and results in policy and implementation gaps (2019).

5.3 The traditional methods including clinical and medical studies leading to low level of accuracy in

prediction of suicide risks is a very high in cost to the veteran community

According to Thompson P., et.al (2014), the best prediction of suicide risks leading to suicide death using public

clinical and mental health data is about 46%-69%. From the Military perspective, the suicide is the second-leading

cause of death among military personnel and more service members dying by suicide than by combat-related causes

(Thompson P., et.al 2014).


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Australian overall cumulative spending in the last 10 years on mental health is over $1 Billion and in USA and

UK, the cost is between $2-$5Billion, yet no significant reduction in suicide risks world-wide, including Australia.

We believe, the funding if it is 5% of funding shifted to social services that it would significantly reduce the

stress, psychological aspects of individual concerns rather than bulk funding on clinical studies and medical research.

5.4 Inefficiency in the paper-based case management policy and process management

This data is currently paper-based systems, siloed and poorly managed, which lead to inefficiency in case

management. The key points are the lack of visibility and the inefficiency in Case management due to its paper-based

systems and delays in processing primary claims. The Returned Services League noted that the suicide data is

convoluted with deaths that are not definitively suicides. “Too many individuals are suffering from the poorly managed

circumstances at the present time without the necessary care and supervision that’s required from a number of appointed

agencies” (Doolan, 2011) According to Dr. Alex Collie of the Insurance Work and Health Group, each DVA office

performs different claims management functions. In practice this results in claims being handed over from one office

to another throughout the course of a claim, which may also have an impact on decision making and timeliness of

claims processing (2019: 38). This process of reliance of paper-based systems and change of case worker from various

locations evidences ineffective case management impacting time taken to process Veteran primary claims. The

Veterans’ Advocacy and Support Services Scoping Study reported that the primary complaint received to the study

was the length of time taken to process primary claims and the inefficient handling by DVA as responsible for the

significant proportion of the delays (2018:50). DVA can improve the efficiency of high TTTP claims processing by

reducing the amount of ‘inactivity’ (delays in the actioning of a claim despite the presence of required information)

and through the more structured management of medical specialists. The monitoring and reporting of claims are not

effective in alerting management to those which are at risk of taking excessive time to process (2018:43). There were

two main reasons for ‘inactivity’: where claims were effectively ‘lost’ in the system, and where the delegate did not

immediately take action after requested information was received and the claim was actionable. Both issues are

indicative of a lack of transparency over workflow within the system (Collie, 2019:38). The DVA has important data

sharing relationships with Defence and the DHS that if operating effectively, would better enable the DVA to better

perform its claims management function, and to understand the drivers of poor mental health in compensated veterans

(ibid).

5.5 Social study challenges compared to clinical studies for mental health

There is a tendency to undermine the social studies for the root cause analysis of veteran suicide because they

are not compared to clinical or medical. However, we argue this the weakest link in all the mental health and veteran

suicide studies. This social science-based studies will include handling and the implementation of the polices,

processes, human services, workflows, and quality of veteran service delivery. Capture these set of data and conjointly

predict suicide risks will increase the validity of the risk prediction and that directly relevant to the veteran’s moral,

physical and mental health issues.

Today, no work has been done on the root cause analysis on this area of social studies that potentially collect

the data on the tracking of the effectiveness of the policy, processes and the implementation of these for case

management and the effective governance on the human services and case management workflows.

The data in such context contains a lot of information about time, location, event, behaviour, ident ity (people),

features, context, the provenance of the data, responsibility, accountability etc. and these data sets have been neglected.

By using conjoint analysis with multi-stakeholder and multiple data sources for suicide risk prediction will results in

better governance, policies, process, and service delivery for veteran services. These data sets are distinguished from

the data from clinical studies, mental health research, and psychological intervention and should be integrated into the

suicide risk management, prediction and prevention.

This is a social science-based research addressing human services management, processes and policy dealing

with cases, rather than clinical or medical research that may contribute to suicide and predicting suicide risk from the

stakeholders of the special social communities’ data repositories.

6.0 Technology Challenges in Case Management & Suicide Prevention

The 2016 Senate Committee Inquiry recommended that the Department of Veteran Affairs (DVA)’s adopt a

fully digitalized comprehensive case management for Military, ex-members and veterans. It helps increase the


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compliance, improve audit results, supports policymakers’ vision for better serving Military history, culture and veteran

communities. Prof. Alex Collie of Monash University discussed the implemented processes that have improved veteran

claim practices. DVA has established a Single Access Mechanism (SAM) with Defence that is intended to enable the

rapid provision of service information to the DVA to support efficient claims determination. Several initiatives are

underway to improve the exchange of information, including the early registration of serving ADF members with DVA

and providing direct access for DVA staff to Defence eHealth records. DVA uses a number of systems to support its

decision-making, which are being progressively integrated and replaced. ISH is hosted by DHS, and DVA also relies

on its own back-end systems to support its decision-making. Improved access to data offers the opportunity to transform

claims processes, where data-based claims triage involves daily data feeds from claims information systems to segment

clients into risk categories that are then streamed into tailored claims management pathways (2019:38). Furthermore,

the Australian Government has funded a range of services, including a single platform for the delivery of digital mental

health tools to those in need of support, specifically aimed for veterans at risk of suicide. The Veteran Mental Health

Strategy provides a framework on suicide prevention with emphasis on promotion, prevention, and early intervention

to support members and veterans with mental health issues. The 2016-17 Budget allocated funding to continue the

Operation Life suicide awareness and prevention workshop as an approach to curb veteran suicide. The Operation Life

online tool and suicide prevention resources to enhance the safety of those experiencing suicidal ideation with the

support of a clinician (DVA, 2016:10).

Emerging contemporary services and technological advancements in areas of mental health are available to

military and ex-serving community, to support the changing needs required for the veterans and their families. The

Open Arms Veterans & Families Counselling website has access to essential apps and online resources for 24 hours

support for veterans and their families. Positively, the apps and online resources are available to assist in maintaining

mental and physical health by helping veterans in a range of circumstances ranging from dealing with suicidal thoughts,

the management of symptoms incurred from trauma, building stress and resilience and the management of alcoholic

consumption (www.openarms.gov.au, 2020). The Open Arms Veterans & Families Counselling portal and Veterans

and Veterans families Counselling Service (VVCS) websites serve as primary digital entry points for information on

mental health and how to access professional support. The VVCS website enables veterans and their families to self-

manage their mental health through veteran-specific and community-based digital interventions. In addition to these

resources, other mobile apps (including PSTD Coach Australia, High Res, The Right Mix) e-learning programs, social

media pages (Facebook & Instagram) are available to address mental wellbeing and promote support services available

to veterans.

Big Data management using artificial intelligence and machine learning for suicide prevention or ‘at risk’ case

management of veterans will assist to provide the opportunity-

• For a deeper understanding of suicide patterns and risks;

• To gain a greater knowledge of the critical factors and systemic issues that contribute to veteran suicide

death;

• To use predictive analytics for early detection and prevention of the death by suicide;

• To demonstrate timely support for the mental health issues and needs of veterans;

• To use predictive analytics platform for early identification, supervision, and control of suicide risks;

• For better support for the Military and veteran community;

• For increased resilience and maintenance of Military capabilities;

• To aid more visibility and risk situation awareness for effective case management; and

• For possible adoption of an analytical framework for application to other vulnerable and minority groups.

It is suggested that the use of Artificial Intelligence and machine learning for veteran suicide prevention and

case management is timely and achievable, if combined with Social Sciences, Science & Engineering-based applied

research that addresses the need of:

• An analytical understanding of factors and systemic issues that contribute to suicide death though A.I, and

• Predictive analytics techniques and a platform for early suicide risk detection and prevention.


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Bryan, C.J, Thompson, P., Puolin, C. (2014) explain how predictive analytics could demonstrate the probability

of attempted veteran suicide using raw numbers of data. Case managers could assess the impact of interventions against

raw data and measure the relationship of attempted suicide reduction and suicide in veteran populations. The study

known as the Durkheim Project demonstrates, “effective suicide risk prediction systems can be built on the integration

of machine learning methods and experts” in the field. Additionally, clinical studies carried out indicate, “Supervised

machine learning techniques can uncover predictive risk factors that are not clearly understood by the medical

community”. The project offers a prediction triage model that aims to improve suicide prevention within active military

and veterans.

7.0 Recommendation for Better Governance in Veteran Suicide Case Management

Integrating online health information technologies with face-to-face services can improve the identification of

people at risk of suicide by using online assessment before face-to-face appointments to enable an appropriate and

timely response from service providers and facilitate rapid identification of individuals at risk of progressing to more

serious mental illness. The Project Synergy online platform is differentiated from others in use health information

technologies as it focused on supporting existing health services to be more effective in delivery of care at scale. The

research and development cycle of the project, “Not only do online health and wellbeing technologies address

traditional geographical, economic and human resource barriers, they can also provide a valuable platform for

screening, prevention, early intervention and referral processes” (Hickey,I., Davenport, T., Burns, J.M., 2019). The

Project Synergy report details that the [cycle] has a rapid turnaround and it’s crucial that the turnaround is rapid because

new evidence based innovations are continuously being developed and they must keep pace with the rapid rate of new

and emerging technologies being released on a daily basis (ibid).

In October 2017, following the Committee recommendation that while the Veteran Centric Reform (VCR)

program is being implemented that the Australian Government will continue to fund measures to alleviate claims

processing staff and reduce the backlog of claims and, increase case coordination staff to assist clients with complex

needs. The Australian Government committed $4.0 Million over two years to pilot a personalized and veteran-centric

case management service for at risk veterans who may require additional support immediately following their discharge

from the military (2017). Professor Alex Collie reviewed the trial program, the VCR is a major six-year program of

work that commenced on 1 July 2017, and has received funding of $166.6 million (2017/18) and $111.9m (2018/19)

in the first two years. The program includes nine work streams that collectively seek to transform business processes,

improve service delivery and redevelop information and communication technology. An overarching objective of the

VCR program is to move the DVA to a proactive claims management model from its current reactive approach. A

major focus of the VCR programs is on the digitization of DVA processes and enabling better use of data and analytics

(Collie, 2019:33).

8.0 Better Governance in Suicide Case Management and Addressing Person-at-risk

Carers Australia NSW, a non-government organization responded to the inquiry with a focus on suicidality

rates of veteran’s partners. Given the high incidence of suicidality and mental health conditions among veterans and

ex-service personnel, the submission drew on research regarding mental health carers, including those exposed to

suicide, in addition to evidence specifically relating to carers of veterans. Alarmingly, the relative risks for suicidal

ideation, planning and attempts were 7.9, 9.7 and 13.8 times higher for veterans compared with the Australian

population and for partners were 6.2, 3.5 and 6.0 times higher than the general population (O’Toole, 2015). Family

members, partners and friends play a key role in the lives of people living with a mental health condition… Many

experience stigma and isolation and feel overwhelmed by a complex service system. Mental health carers who have

been exposed to suicide are reported to have difficulty accessing and understanding the information and services the

care recipient requires. Research indicates that mental health carers, especially those exposed to suicide, need simpler

service pathways and better information and support as they navigate service systems (Carers Australia NSW, 2016).

Prof. Philip Morris, a psychiatrist explains that isolation from others is a powerful risk factor for suicide. Perhaps the

most important thing that can be done to prevent suicide is to connect the person at risk with individuals from caring

networks of peers, family, and professionals. Personal contact with the person at risk by one or more of the individuals

from the caring network reduces isolation and improves self-esteem – both likely to increase the threshold against self-

harm. This will mean a more accepting attitude of veteran-based rehabilitation programs that focus on social inclusion

and participation (2020).


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9.0 Conclusion

Despite recent improvements to the compensation claims system reform there is a requirement to review the

current Veteran’s compensation and rehabilitation processes. The DVA processing times were lengthy and

administering claims have been described as unnecessarily adversarial and complicated. In conclusion, there appears

to be multiple opportunities for the DVA to introduce further reforms to its compensation claims processing model, in

order to mitigate any potential impact on veteran mental health. Best practice is moving from a liability and cost

focused, claims processing model to a health and function focused, client-centered model (Collie, 2019:7). It is in the

best interests of veterans, their families and the Australian community for the Australian Governments to adopt efficient

administration practices – a simpler and easier system to navigate, a greater focus on prevention of injury and mental

health with improved rehabilitation and responsive traditional support to meet the future key challenges and emerging

needs of veterans.

References:

ANAO Report No.52, 2017–18 Efficiency of Veterans Service Delivery by the Department of Veterans’ Affairs.

Anzac House (2019), Returned & Services League of Australia, Submission 19, July 2019, Australia

Asadabadi, M.R., Saberi, M., & Chang, E. (2018). The concept of stratification and future application. Applied Soft

Computing, 66, 292-296.

Asadabadi, M.R., Saberi, M., & Chang, E. (2018). Targets of unequal importance using the concept of stratification in

a big data environment. International Journal of Fuzzy Systems. 20(4), 1373-1384.

Australian Government, Attorney General’s Department, 2020. National Commissioner for Defence and Veteran

Suicide Prevention, https://www.ag.gov.au/about-us/national-commissioner-defence-and-veteran-suicide-prevention

(Accessed 28 August 2020)

Australian Government, Australian Institute of Health and Welfare, 2019. National Suicide monitoring of serving and

ex-serving Australian Defence Force personnel: 2019 update https://www.aihw.gov.au/reports/veterans/national-

veteran-suicide-monitoring (29 November 2019)

Australian Government, Department of Defence, 2015. GUARDING AGAINST UNCERTAINTY: AUSTRALIAN

ATTITUDES TO DEFENCE, https://defence.gov.au/WhitePaper/docs/GuardingUncertainty.pdf (Accessed 30 August

2020).

Australian Government, Department of Defence, 2016. Senate Standing Committee on Foreign Affairs, Defence and

Trade Inquiry into Suicide by Veterans and Ex-Service Personnel, Submission 123, October 2016

Australian Government, Department of Veteran Affairs, Case Management Services, https://www.dva.gov.au/health-

and-treatment/work-and-social-life-programs/wellbeing-and-support (Accessed 3 June 2020)

Australian Government, Veterans’ Advocacy and Support Services Scoping Study, A modern professional sustainable

service for Australian Veterans and their families, Report (December 2018), p.50

Australian Government, Department of Veteran Affairs, 2016. Senate Standing Committee on Foreign Affairs, Defence

and Trade Inquiry into Suicide by Veterans and Ex-Service Personnel, Department of Veterans’ Affairs Submission,

Submission 156, October 2016, page 3.

Australian Government, Department of Veterans’ Affairs, Efficiency of Veteran’ Service Delivery, ANAO, June 2018,

p 43.

Australian Government, 2017. Australian Government response to the Foreign Affairs, Defence and Trade Committee

report: The constant battle: suicide by Veterans. Tabled by the Minister for Veteran Affairs.

https://www.dva.gov.au/about-us/overview/what-we-must-report/reviews-and-reports/government-reports/constant-

battle-suicide (October 2017)

Australian Government, Productivity Commission. A Better way to Support Veterans. Productivity Commission

Inquiry Report, Overview & Recommendation. No 93, 27 June 2019, p.5

Bryan, C.J, Thompson, P., & Puolin, C. (2014), Predicting Military and Veteran Suicide Risk: Cultural Aspects,

DOI: 10.3115/v1/W14-3201


https://www.ag.gov.au/about-us/national-commissioner-defence-and-veteran-suicide-prevention

https://www.aihw.gov.au/reports/veterans/national-veteran-suicide-monitoring

https://www.aihw.gov.au/reports/veterans/national-veteran-suicide-monitoring

https://defence.gov.au/WhitePaper/docs/GuardingUncertainty.pdf

https://www.dva.gov.au/health-and-treatment/work-and-social-life-programs/wellbeing-and-support

https://www.dva.gov.au/health-and-treatment/work-and-social-life-programs/wellbeing-and-support

https://www.dva.gov.au/about-us/overview/what-we-must-report/reviews-and-reports/government-reports/constant-battle-suicide

https://www.dva.gov.au/about-us/overview/what-we-must-report/reviews-and-reports/government-reports/constant-battle-suicide

https://www.researchgate.net/deref/http%3A%2F%2Fdx.doi.org%2F10.3115%2Fv1%2FW14-3201

3




24

Bunker, P. (2016), Australian Government, Department of Defence., Senate Standing Committee on Foreign Affairs,

Defence and Trade Inquiry into Suicide by Veterans and Ex-Service Personnel, Submission 102, October 2016

Carers Australia NSW, 2016. Senate Standing Committee on Foreign Affairs, Defence and Trade Inquiry into Suicide

by Veterans and Ex-Service Personnel, October 2016.

Collie, A., The Mental Health Impacts of Compensation Claim Assessment Processes, The Insurance Work and Health

Group, School of Public Health and Preventive Medicine, Monash University. (March 2019) p.5.

Collie, A., 5 March 2019, The Mental Health Impacts of compensation Claim Assessment Process, Monash University,

p.7

Doolan, K. (2011) National President Report, RSL National Annual Report, RSL National Congress 2011.

Foley, D, (2016) Australian Government, Department of Defence., Senate Standing Committee on Foreign Affairs,


Gursansky, D., Kennedy, R., & Harvey, J. (2003), Case Management: Policy, Practice and Professional Business.

Routledge: London.

Hickie, I., Davenport, T., Burns, J. (2019) Project Synergy: co- designing technology- enabled solutions for Australian

mental health services reform, Australian Medical Journal. doi: 10.5694/mja2.50349

Hussain,O., Chang, E., & Dillion, T.S. (2013). ‘Risk Assessment and Management in the Networked Economy’,

Springer: Heidelberg, IBSN 978-3-642-28689-6.

Johnstone, J., D. O’Connor. (2009), Implementation and Evaluation of Maryland Social Services Administration’s

Screening and Response Time Assessment, CRC

Lane, D. (2016) Australian Government, Department of Defence., Senate Standing Committee on Foreign Affairs,


Leonard, J. (2016), Australian Government, Department of Defence., Senate Standing Committee on Foreign Affairs,

Defence and Trade Inquiry into Suicide by Veterans and Ex-Service Personnel, Submission 104, October 2016, p.1.

Lumary, Better Wellbeing Through Technology, www.lumary.com.au, (Accessed 16 march 2016).

Name withheld, (2016), Australian Government, Department of Defence., Senate Standing Committee on Foreign

Affairs, Defence and Trade Inquiry into Suicide by Veterans and Ex-Service Personnel, Submission 79, October 2016

MacDonell, G, (2016), Australian Families of the Military Research Foundation Limited, Senate Standing Committee

on Foreign Affairs, Defence and Trade Inquiry into Suicide by Veterans and Ex-Service Personnel, Department of

Veterans’ Affairs Submission, Submission 164, October 2016, page 3.

Maher, B. (2020), Conference Introduction, in National Suicide Prevention Conference, CEO and Global Director,

Mental Health and Suicide Prevention, Australia

Menz, Dave (25 November 2019), Australian Peacekeeper and Peacemakers Veteran Association Vic Branch (APPVA

Vic)

MHPW Study (2010). Military Mental Health Prevalence and Wellbeing Study. University of Adelaide.

Morris, Philip. (2016), Senate Standing Committee on Foreign Affairs, Defence and Trade Inquiry into Suicide by

Veterans and Ex-Service Personnel, Submission 384, October 2016

Morris, P. (2020) Suicide by veterans and ex-service personnel, Submission 384. Nice Steps that will halt suicide in

Australian defence Force (ADF) members and ex-ADF, www.aph.gov.au (accessed 11 May 2020)

Morrison, Scott (2020), Prime Minister of Australia, “Announcement of National Commissioner for Defence and

Veteran Suicides”, National Press Conference, Canberra, Australia, 6 January 2020

Open Arms Veterans & Families Counselling, https://www.openarms.gov.au/resources/apps-and-online-resources

(Accessed 20 August 2020)

O’Toole BI, et.al., Suicidality in Australian Vietnam veterans and their partners, Journal of Psychiatric Research

(2015). http://dx.doi.org/10.1016/i.ipsychires.205.02.003


http://www.lumary.com.au/

http://www.aph.gov.au/

https://www.openarms.gov.au/resources/apps-and-online-resources

3




25

Sen. Lambie, J. (13 February 2020) These medals aren’t free, www.lambienetwork.com.au/thesemedalsarenotfree,

(Accessed: 30 August 2020)

Scally, Steven. (2016), Australian Government, Department of Defence., Senate Standing Committee on Foreign

Affairs, Defence and Trade Inquiry into Suicide by Veterans and Ex-Service Personnel, Submission 59, October 2016

Skynews.com.au, 29 June 2020, Julie Ann Finney interview

Soldier On. (2016), Senate Standing Committee on Foreign Affairs, Defence and Trade Inquiry into Suicide by Veterans

and Ex-Service Personnel, Submission 175, October 2016

The Case Management Society of Australia & New Zealand & Affiliates, www.cmsa.org.au (Accessed: 31 August

2020)

The Partners of Veterans Association of Australia. (2016), Senate Standing Committee on Foreign Affairs, Defence

and Trade Inquiry into Suicide by Veterans and Ex-Service Personnel, Submission 45, October 2016

Thompson P. Poulin C., Bryan C.J. (2014) Predicting military and veteran suicide risk: Cultural aspects, Workshop

on Computational Linguistics and Clinical Psychology: From Linguistic Signal to Clinical Reality, pages 1–6,

Baltimore, Maryland USA, June 27, 2014.

Ventham, Arthur. (2016), Senate Standing Committee on Foreign Affairs, Defence and Trade Inquiry into Suicide by

Veterans and Ex-Service Personnel, Submission 295, October 2016

Zadeh, L.A., (2016). Stratification, target set reachability and incremental enlargement principle. Information

Sciences, 2016. 354:p. 131-139

Zaniolo, C. (2015). Expressing and supporting efficiency greedy algorithms as locally stratified logic programs,

www.researchgate.net/publication/283813612_Expressing_and_supporting_effeciently_greedy_algorithisms_as_loca

lly_stratified_logic_programs.

Zinn, D., & Ludaescher, B., (2010), “Abstract Provenance Graphs: Anticipating and Exploiting Schema Level Data

Prevalence”, Lecture Notes in Computer Science book series (LNCS, volume 6378)


http://www.lambienetwork.com.au/thesemedalsarenotfree

http://www.cmsa.org.au/

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